Highland Hospital Department of Emergency Medicine Visiting
Highland Hospital Department of Emergency Medicine Visiting Elective Scholarship Program (VESP) Application for the Highland Hospital Emergency Medicine VESP Please submit the following materials: Completed VESP application (see next page) Leadership and Research Experience Background Personal Statement Completed VSAS (Visiting Student Application Service) application to the Highland Hospital Emergency Medicine Clerkship EM: 140.40, including all requirements as detailed in the application. Submit all VESP application materials by mail or email to: Highland Hospital Emergency Medicine Visiting Elective Scholarship Program Dr. Caitlin Bailey, MD c/o Jackie Alberto Highland Hospital, Alameda Health System Department of Emergency Medicine Room 6412 1411 East 31st Street Oakland, CA 94602 Email: [email protected] For email please specify in the subject that this is the scholarship application. Thank you! Highland Hospital Emergency Medicine VESP APPLICATION FORM (To type your information on this page, use your mouse to go to the grey box on the form. Enter text, or use your mouse to click the appropriate check box.) The Applicant: Last Name First Name Current address City State Permanent address Birth date Zip City State Zip Primary Email Alternate Email Home Telephone Gender: Mobile Phone Female Male Sexual Orientation: (OPTIONAL) Specify only if you choose to share this information. Not required. Your Current Medical School: Current Year at your Medical School (please check one) 3 4 Other: please specify: Expected Date of Graduation: Citizenship: U.S. Citizen U.S. U.S. Noncitizen National Do you have a Social Security Number? Permanent Resident of Yes No Do you have a disability? (physical or mental impairment that substantially limits one or more major life activities) *Yes No Do not wish to provide *If disabled, which of the following describes your disability(ies)? Hearing Visual Disadvantaged Background: Mobility Other: Yes No IF YES, please check category: Family with an annual income below established lowincome thresholds. Social, cultural, or educational environment such as that found in certain rural or inner city environments that have demonstrably and recently directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a medical career. First Generation in Family to Attend College: Yes No Race/Ethnicity: What is your racial background? (OPTIONAL. Check all that apply.) African American/Black Nativeborn Black American African (origin in black racial group) Haitian West Indian Asian Bangladeshi Burmese/Myanmarese Chinese Filipino Indian Indonesian Japanese Korean Laotian Malaysian Nepali Pakistani Sri Lankan Thai Vietnamese Other Asian, specify Caucasian or White (of Europe, North Africa, or the Middle East) Hispanic/Latino Central American Mexican Cuban South American, specify Puerto Rican Other Hispanic, specify Native American American Indian Native Alaskan Native Hawaiian Pacific Islander Fijian Guamanian Marshalleses Melanesians Micronesians Polynesians Samoan Tahitian Tongan Other Pacific Islander, specify Prefer not to disclose How did you learn about our program? (Please answer with only a few sentences) Leadership or Research Experience or Publications List and very briefly describe prior leadership and research experience with dates, if any, and any articles/abstracts published in referred journals. (Attach additional sheet if necessary and please list in a CV format). A complete CV is also welcome. Personal Statement Applicant: Either cut and paste or type directly into the grey box below. (Not to exceed 500 words) Instructions: Please describe how your background has influenced the type of physician you want to be and the type of communities that you want to serve. Please also include any experience in working with diverse communities and future plans upon completing residency training. Finally, in a very brief paragraph include a few sentences about your interest in Emergency Medicine. A statement of need: In less than 250 words please explain how this scholarship will benefit you.
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